Improving Health Care for Homeless People

Addressing the medical issues of homeless people is the health equity challenge of our time. The most recent US Department of Housing and Urban Development (HUD) report on homelessness, published in 2015, estimated that about 564,000 homeless people in the United States live in shelters and on the streets. This figure, based on a point-in-time snapshot on a single night each January, may well be an underestimate, given varying definitions of homelessness, peripatetic populations, and the lack of robust surveillance systems.

Some estimate as many as 2.3 million to 3.5 million individuals experience homelessness each year; persons of color are disproportionately affected, with one-third unsheltered.

This vulnerable population comprises a human kaleidoscope of people often excluded from mainstream society: runaways, LGBT (lesbian, gay, bisexual, and transgender) youth, those targeted by domestic violence, struggling veterans, displaced factory workers, migrant laborers, refugees, illiterate individuals, fragile elderly persons, and those discharged from mental hospitals or overcrowded prisons. For many, the daily struggle for food, shelter, clothing, and safety relegates health to a distant priority which, in turn, exacerbates disease, complicates treatment, and drives excess mortality. One recent analysis shows death rates for homeless youth are more than 10 times greater than for the general population.

More than 250 health care for the homeless (HCH) projects, funded by the Health Resources and Services Administration as federally qualified health centers, now feature multidisciplinary teams of clinicians that use an array of dedicated care strategies.

A decade ago, strategies for housing usually involved a treatment-first, continuum-of-care approach, in which clients were required to progress through milestones (such as sobriety, psychiatric treatment, and independent living skills) before being offered a home. Current federal efforts now favor “low-threshold supportive housing.” This is particularly true of Housing First, which offers timely access to a home without such requirements, thereby providing clients opportunities to link quickly with caregivers who can help address mental and physical health needs.

Insurance and Health Care Financing

Medicaid expansion in 32 states as part of the Affordable Care Act now provides new insurance options for people experiencing homelessness, especially previously ineligible single adults. In expansion states, health coverage rates for patients in HCH projects increased from 45% in 2012 to 67% in 2014 vs 26% to 30% in nonexpansion states during the same period. Through various waiver and plan options, states can request that the CMS approve Medicaid plans that cover housing costs, as long as the plans are cost-saving or cost-neutral.

The US Interagency Council on Homelessness coordinates national efforts with 19 federal agencies, state and local governments, and service providers. Other leading groups to address homelessness and its associated health challenges include the National Alliance to End Homelessness, the National Coalition for the Homeless, the National Health Care for the Homeless Council, the Corporation for Supportive Housing, and the Mayors Challenge to End Veterans Homelessness.

Despite some progress over the last several decades, the obstacles remain monumental. Accelerating efforts to reduce health disparities will require even greater societal commitment to improve health for this most vulnerable population.

Many of us are concerned about the unmet medical needs of the homeless, yet we fail to see adequate attention being paid to supporting public policies that would better address these needs. As Koh and O’Connell indicate, that means providing housing as well as access to health care and to programs that pay for these needs.

An egalitarian single payer healthcare system with first dollar coverage – an improved Medicare for all – obviously would go a long way toward providing access to health care. But providing housing and other essential needs would also be required for those who do not have the capability of meeting their own needs.

It is interesting that Medicaid waivers can be granted to include housing “as long as the plans are cost-saving or cost-neutral.” Wow. Considering that Medicaid is already severely underfunded, you would think that the government would have problems with the concept of drawing down Medicaid funds even further just to help fund housing. You might think that, but apparently not.

Holiday season seems to have become a time to pity the homeless, maybe a time to even donate a couple dollars to a soup kitchen, but not really a time for action. But as Koh and O’Connell remind us, the obstacles for progress remain monumental. “Accelerating efforts to reduce health disparities will require even greater societal commitment to improve health for this most vulnerable population.” Societal commitment means all of us, including Mr. Trump.

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Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.